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Though 26 states decided against going along with an expansion of the Medicaid health insurance program for the poor under the Affordable Care Act, 17 of them have seen a boost in enrollment thanks to “increased outreach and awareness,” a new analysis indicates.

More than 550,000 new Medicaid beneficiaries signed up for the program in the first quarter of this year in these 17 states, which included Georgia (5.8 percent increase); Idaho (7.5 percent increase); Montana (10.1 percent increase); South Carolina (5.4 percent increase); Oklahoma (4.8 percent increase); and Tennessee (4.3 percent increase), according to Avalere Health, a research and advisory services firm on health policy issues tracking the Affordable Care Act.

While 8 million people signed up for private coverage on government run marketplaces known as exchanges, several million more Americans signed up for Medicaid coverage under the President’s signature health legislation through the expanded Medicaid program. Despite the opportunity to increase Medicaid benefits at little cost to state taxpayers, there remain holdouts like those documented in the Avalere report.

Yet even in the “non expansion states” consumers were subject to an advertising and marketing blitz to sign up for coverage. Analysts reason many found out they were previously eligible for Medicaid regardless of the health law’s expansion during overall promotion of the Affordable Care Act.

The federal government traditionally picks up a little more than half of the cost of Medicaid. But funding under the health law is unlike past efforts to expand Medicaid in that the federal government will pick up the full tab for the first three years. The state gradually has to pick up some costs in 2017, but by 2020, the federal government is still picking up 90 percent or more of the Medicaid tab.

The costs of not expanding Medicaid for some states may also come on top of a provision under the Affordable Care Act that requires insurance companies pay a fee to help fund the law and expand benefits to the poor and uninsured.

State Medicaid programs and health insurance companies that contract with states to provide benefits to Medicaid beneficiaries are seeking clarity from the Obama administration on how to properly account for the new insurance tax.

It’s an important issue for the health insurance industry given an increasing number of state Medicaid programs are contracting with private health insurance companies like (AET), (HUM), UnitedHealth (UNH), Centene (CNC) and Molina (MOH). More than 35 states and the District of Columbia contract with health to help manage their insurance programs for the poor.

“Medicaid health plans and states need clear written direction from CMS that tells Medicaid agencies that the insurance tax and the income tax effect must be factored into the rate-setting process and covered in payments to plans,” Myers wrote.